The principles and practice of modern surgery

Two dangers attend inexcusable delay in such acute cases—one is of suffocation from pressure or from sudden spontaneous rupture of abscess; the other is of invasion of large blood trunks in the vicinity and possibility of hemorrhage after erosion, either into the abscess cavity or directly into the outer world.

THE UVULA AND SOFT PALATE.

ELONGATION OF THE UVULA.

As the result of constant irritation by coughing, or other reflex motions of the pharyngeal muscles produced by local irritation, the uvula frequently becomes elongated to a point which permits it to rest upon the base of the tongue and there to produce still more irritation and reflex phenomena. Patients suffering in this way will be noticed to make frequent attempts at swallowing and coughing, which may be depressing, and may lead to disturbed sleep and even an asthmatic form of breathing. The uvula is a useless organ when it has attained such dimensions, and its amputation, or at least its shortening, are indicated in all such cases as those above described. Local anesthesia is sufficient. Its tip is caught with a pair of forceps and it is clipped off, not too near its base, by long-handled and sharp scissors. This is a much neater and more expeditious method than to include it within the grasp of a wire snare and somewhat slowly crush it off.

Upon the uvula, as upon the soft palate, papular lesions of syphilis are frequently seen, rarely the primary chancre, but very often mucous patches or the deeper ulcers, which characterize the secondary and tertiary lesions. Gummas also may form within the thickness of the palatal tissues, which will in time break down and form ragged ulcers, while the destruction may extend to the bony portions, either of the nose or roof of the mouth, and then necrosis will be added to the evidences of ordinary ulceration. The rapidity with which these specific lesions will disappear under prompt and vigorous constitutional treatment, along with that local cleanliness which should include removal of necrotic tissue, is surprising and gratifying.

THE EPIGLOTTIS.

The epiglottis is composed of yellow elastic cartilage and it does not tend to calcify during the later years of life, as does the white or fibrocartilage of the balance of the larynx. Thus its elasticity and flexibility are fortunately maintained throughout life. It may be sometimes injured by the incised wounds elsewhere described under the term “cut-throat,” and is at least often thus exposed when not actually injured.

The epiglottis seems to be exempt from most of the primary diseases, but is occasionally involved in lesions of surrounding tissues, in which it may then participate. Thus it may be deformed by cicatricial tissue and unduly bound down, or it may succumb to advancing ulceration of syphilis, tuberculosis, or cancer. Injuries which break the laryngeal box rarely affect the epiglottis because of its elasticity.

While an extremely useful portion of the body, the epiglottis is not an absolute necessity, for even after its removal individuals can swallow, although the act requires some extra care. Should the epiglottis become involved in cancerous disease it should be removed with the rest of the diseased tissue, while syphilitic and tuberculous lesions will usually prove amenable to a combination of local and general treatment. New-growths in this region are extremely uncommon, but will prove relatively easy of removal when present.

THE LARYNX.

The laryngeal cartilages, save the epiglottis, are composed of white fibrocartilage which manifests a tendency in the later years of life to undergo calcification. This makes the organ less elastic, changes the tonal qualities of the voice, and makes it more brittle and subject to possible fracture by external violence. Fractures of the organ, as of the adjoining hyoid bone, have been elsewhere discussed, with the indications which may make an emergency tracheotomy necessary because of hemorrhage or edema of the narrow laryngeal passage.

Of the inflammatory affections of the cartilages chondritis and perichondritis are most common. These are usually seen in connection with other expressions of tuberculous, syphilitic, and malignant disease. Nevertheless they are known to occur as sequels of the exanthems and ordinary infectious fevers. They may be followed by destructive ulceration, which will lead to a necrosis of the cartilage corresponding closely to death of bone under similar circumstances. In due time there may form a cartilaginous sequestrum, and this will require removal as though it were bone. Dangers attend these lesions in two peculiar directions. The very condition which produces the destructive inflammation may also produce either hemorrhage or edema, with suffocation which can usually be prevented by an emergency tracheotomy. On the other hand, when repair follows spontaneous recovery or successful treatment, it may be accompanied by such cicatricial contraction as shall materially change the shape and impair or possibly destroy the function of the larynx itself. In this case either thyrotomy, tracheotomy, or laryngotomy may be called for, the opening thus made being expected to permanently remain.

STRICTURES OF THE LARYNX.

Various forms of stricture of the larynx may be similarly produced. Such strictures, then, are due to previous disease or to injuries, and here as elsewhere stricture is a consequence rather than itself a disease. It occurs in consequence of syphilis and of the destruction following laryngeal diphtheria.

What is, in this respect, true of the larynx is also true, though less often, of the trachea, where constrictions may occur at various points, with reduction of caliber or such distortion of shape as to produce partial or even finally complete obstruction. The peculiar scabbard-shape which the trachea may be made to assume by compression between the lobes of a growing goitre has been elsewhere described. While the trachea itself is in this case free from disease the obstruction is none the less pronounced. Similar effects are produced by pressure, as from aneurysms or tumors, even at a distance. Loss of voice, shown to be due to paralysis of one or both vocal cords, should always prompt an examination of the chest, in order that the presence of an aneurysm or other tumor making pressure upon the recurrent laryngeal may not be overlooked.

Symptoms.

—Symptoms of laryngeal and tracheal stricture comprise (1) those of the primary and active disease which produces them; (2) those of obstruction; (3) those of suffocation in emergency cases. The earlier symptoms are those of increasing dyspnea, which may vary in rapidity and extend over weeks and months, or which may become most pronounced within a few hours. There is also a change in the character and sometimes complete loss of voice, hoarseness of the speaking voice changing into a whisper. The condition is frequently complicated by attacks of serious dyspnea, often at night, which are due to an added spasmodic feature, and in which death may suddenly occur. Usually, however, with asphyxia comes muscular relaxation, and individuals may pass through a large number of these attacks, which are accompanied with extreme mental and physical suffering, in which death is only avoided by final relaxation. Again the heart may suddenly give out, and then the case becomes practically hopeless. In recognition of causes and location of such troubles it may be held that when hoarseness precedes dyspnea the lesion is in the larynx; when the reverse, it is in the trachea. Careful auscultation of the chest and thorough laryngoscopic examination will usually enable the lesion to be recognized. The lower the location of the stenosis the worse the prognosis, because of its inaccessibility. So long as the trachea below the stricture can be opened life may be prolonged indefinitely; but when due to a mediastinal tumor or an enlarged thymus, the case assumes desperate aspects and may baffle the best-directed efforts.

Treatment.

—Strictures in the larynx proper may be treated by dilatation, as by the introduction of intubation tubes of increasing size, a method which ordinarily gives satisfactory results. Nevertheless such laryngeal strictures manifest an almost permanent tendency to recontract, and whatever measures are addressed to them have to be frequently and thoroughly practised and over a long period. Fortunately, however, these patients are able to wear an O’Dwyer tube nearly all the time. When these internal operative methods fail there remains only an external opening, which may be made through the larynx proper (thyrotomy), or a low tracheotomy, which may require the insertion of short or long tubes, according to circumstances. Long trachea tubes are made, their lower portion being composed of rings fastened together in such a way as to cause them to be called lobster-tailed, and such a long tube may be passed through a low tracheotomy opening and made to extend beyond the point of pressure produced by an extrathoracic or an intrathoracic tumor. By the use of such an expedient life may be prolonged, although the exciting cause may prove fatal.

TUBERCULOSIS OF THE LARYNX.

Tuberculosis of the larynx may appear in a generally disseminated form, involving nearly all the structures, or in circumscribed localized form, as a tuberculous ulcer, which may produce symptoms depending upon its exact location. Laryngeal tuberculosis may, moreover, be but a local expression of the disease, apparently primary, or as often happens, it may be an accompaniment of pulmonary tuberculosis, the laryngeal trouble appearing as a local infection, taking place by the constant passage over the surface of tuberculous sputum which the patient is expectorating at frequent intervals. Thus, clinically, we may have a miliary, an ulcerative, or a gummatous form of the disease.

The condition is frequently referred to as laryngeal phthisis, and is mainly to be distinguished from syphilitic laryngitis, or occasionally from commencing malignant disease. Local symptoms include those of chronic laryngeal catarrh, with hoarseness, impairment of voice, sensation of dryness within the larynx, and frequent short, hacking, unsatisfying cough. To these features are later added more or less pain, especially in deglutition, while aphonia will finally succeed dysphonia. When the epiglottis and the structures near it are involved there are more irritation and pain. Dyspnea is a measure of the encroachment upon the breathing space left by the progress of the disease. Infiltration of all the parts within and later of those around the larynx finally takes place, and with further implication nervous reflex symptoms are added to those above mentioned. Cough is usually a distressing feature; the sputum varies in amount; saliva is increased in flow, and the expectoration is frequently streaked with blood. In advanced disease the sufferings of the patient become excessive, while constitutional symptoms keep pace with those of the local disease. Thus anemia, emaciation, debility, insomnia, and general malaise cause the patient great discomfort, and, coupled with his terminal local symptoms, make death an absolute relief.

With the laryngoscope varying pictures may be seen, either of ulceration or of general involvement of the entire interior of the larynx, which will be tumefied, irregularly swollen, ulcerating here and there, while the vocal bands show thickening and roughenings as well as ulcerations. Gummatous outgrowths may be seen at almost any point and in various stages of ulceration. A more distinctly lupoid form of tuberculosis is also occasionally seen in the larynx, where it assumes more of the nodular appearance characteristic of lupus, the nodules coalescing or disappearing by ulceration, which may leave a dense, cicatricial tissue after healing. Primary lupus of the larynx is rare.

Tuberculous lesions of the larynx are mainly to be recognized with the laryngoscope, but they, like all other local diseases in this location, produce alteration and final loss of voice, with difficulty of breathing, reflex cough, and are accompanied by general constitutional symptoms, according as the disease is purely local or an expression of a general affection.

Treatment.

—Treatment should be both local and general. The latter may be summarized by stating that all measures, including proper climatic environment, which are found to be of advantage in ordinary tuberculous disease, will prove of equal advantage here. There should be avoidance of exposure to all irritation—coal gas, tobacco smoke, vitiated air, etc.—while absolute rest of the vocal organs should be prescribed and all attempts at singing or unnecessary speaking be prohibited. All measures regarded as of value in general tuberculosis will find an equally wide field for their activities.

Local treatment is directed toward amelioration of discomfort and improvement of local lesions. The former may be afforded by steam inhalations with some soothing, volatile antiseptic added to the spray, such as methol, oil of eucalyptus, some gentle opiate, or anything that may give local anodyne effect. Cough may also be treated by the milder anodynes, of which cocaine or heroine will serve for most instances. Sleep is to be secured by some of the ordinary hypnotics. Local applications may be made by an applicator guided by the laryngoscopic mirror, by the medical attendant, or through watery or oleaginous solutions in a spray. For absolute local relief a mild cocaine solution, followed by the use of a very weak solution of silver nitrate, lactic acid (C. P.), or even the more thorough treatment of local ulceration by means of the laryngeal curette or touching with the point of the galvanocaustic loop, may give relief. The treatment of laryngeal tuberculosis rarely comes within the domain of surgery proper, until the disease has reached a degree necessitating some radical measure, such as thyrotomy, with erasion of the affected tissue, or possibly a laryngectomy, with complete removal of an organ which is too thoroughly diseased to warrant hope of repair.

SYPHILIS OF THE LARYNX.

Syphilis of the larynx is more common than tuberculosis, the lesions usually belonging to the later stages of the diseases, including especially mucous patches, and the ulcerative expressions, with or without the formation of small gummatous tumors. The loss of voice is rarely as pronounced, and the entire course of the disease is accompanied by less irritative and offensive features than is tuberculosis. Diagnosis will be materially assisted by the discovery of suggestive expressions of syphilis, either in adjoining or distant parts. Thus if mucous patches appear within the larynx they will also be seen within the mouth. Ulcers which are produced by syphilis have well-defined edges, and are rarely multiple; while those produced by tuberculosis are more often multiple, are seated upon an anemic base, produce more distortion of laryngeal structures, and more residue of cicatricial tissue at points where healing has occurred.

Treatment.

—The treatment of laryngeal syphilis is essentially constitutional, for nearly every local expression will clear up under the influence of properly directed remedies. However, when local symptoms are uncomfortable or depressing they may be treated as are those of tuberculosis, by soothing sprays and the local application of anesthetics, astringents, and the like.

INTRALARYNGEAL AND INTRATRACHEAL TUMORS.

Within the larynx tumors may occupy the space beneath the glottis, where they are referred to as subglottic; they may grow from the structure of the vocal cords and become intraglottic, or they may spring from above the glottis and from the aryteno-epiglottic fold. Certain forms of benign tumor are relatively common in this location, while others are almost unknown. The former include cysts, papillomas, fibromas, angiomas, and adenomas, as well as the ordinary granulomas.

A nodular lesion seen upon the vocal cords, especially in singers, which is hyperplastic in character, irritative in origin, and often called “singer’s node,” is frequently found upon the edges of the cords, either as a single or bilateral lesion. The adjoining structures are usually quite vascular. These lesions occur in those who abuse their voices, as, for instance, in amateur singers and newsboys. The nodules themselves vary in size from that of a pin’s head to that of a split pea. The condition produces hoarseness and impairment of the voice, is recognized with the laryngoscope, and is amenable to treatment, which should consist in absolute rest from vocal effort and gentle astringent and stimulating applications. If the node project very far it may be removed by the intralaryngeal guillotine.

Laryngeal polypi include the forms of benign tumor above mentioned, most of which assume in time a polypoid form, and cause impairment of function according to their location.

Papilloma is by all means the most common of these growths, and may present either the vascular type, bleeding easily and growing rapidly, or the firmer and denser type from admixture with fibromatous tissue. It occurs frequently in the young, and may even be present in the newborn. Here it can scarcely be detected with the laryngoscope, but may be felt with the finger. Cysts take their origin from the mucosa, save those which, possibly of embryonic character, protrude into or encroach upon the larynx from without (Fig. 481).

Symptoms.

—The symptoms of benign intralaryngeal growths are largely irritative, including cough, with hoarseness and change of voice, and going on to production of dyspnea in proportion to the size which they attain. Later complete aphonia, with spasm of the glottis, may be the result of their presence, while pedunculated growths, or polypi with long pedicles, may cause aggravated symptoms by circumstances of position, the patient being much of the time relatively free. Hoarseness, dyspnea, and cough, without other evidences of inflammation or epidemic disease, should always lead to careful inspection with the laryngoscope, and this will reveal the size and situation of the growth. These examinations can be made with cocaine and give satisfactory information. Only in young children are they difficult, or sometimes impossible. Even in an infant with a hoarse cry and spasmodic or suffocative attacks the condition may be suspected.

Prognosis.

—The prognosis will depend upon the character of the tumor and the local conditions—i. e., size, fixation, location, etc. In the young it is serious because of the danger attending its removal. Rational adults can be usually put in excellent condition for endolaryngeal operation by the aid of local anesthesia, and expert specialists become dexterous in their manipulation of the specially shaped forceps, curettes, and the like which are required for removal of these growths. As elsewhere a truly innocent tumor in this location does not recur after complete extirpation.

MALIGNANT TUMORS OF THE LARYNX AND TRACHEA.

Of these tumors the most common is epithelioma within the larynx. Sarcoma occasionally originates from the vocal bands, true or false, and will usually form a nodular tumor, of rugose surface, until it begins to ulcerate. Once it begins to break down it is difficult to distinguish from the other varieties without the aid of the microscope; but epithelioma may be met with in any part of the larynx, generally arising from the ventricular bands. Here, as ordinarily upon mucous surfaces, it begins as a small nodule with a definite zone of infiltration about it; if seen early it may be mistaken for innocent papilloma. As infiltration progresses the hoarseness resulting from its presence will change to loss of voice, because of the fixation of the tissues whose mobility is essential to voice production. Pain may be an early feature, depending upon ulceration and exposure of sensory nerve endings. Later when the ulcerated surface has become deep, irregularly covered with fetid discharge, and more or less concealed by edematous surroundings, the picture is more complete in one respect, although the details may be obscure. From the mucous and softer tissues the disease will spread and invade the cartilages themselves, as well as the tissues outside, and so with the progress of the cancer the entire larynx becomes fixed in a bed of infiltrated tissue extending in all directions, involving the upper part of the trachea, the epiglottis, and the base of the tongue. Meantime the loss of voice, the distressing cough, and the other evidences of local invasion will have kept pace with the progress of the disease, and dyspnea will come on sooner or later as the passage-way becomes blocked, while from sudden, violent efforts at coughing acute attacks of edema, which may result fatally, are liable to occur.

Tumors of the trachea proper are far less common. They may be benign or malignant. In either event they will prove to be of about the same type as those already discussed above as occurring within the larynx. They cause less interference with speech, but as much or even more difficulty in respiration.

When tracheotomy was a frequent resort in croup and diphtheria a peculiar form of new formation in the trachea was occasionally encountered, resulting from the irritation of the trachea tube, whose presence sometimes provokes excessive formation of granulation tissue, whose subsequent contraction brings about not only the formation of a dense granuloma, but cicatricial contraction. Hence in the older literature references to granulation stenosis were common. Now that intubation has almost completely replaced tracheotomy for these purposes the latter is rarely performed, and tubes are seldom left more than a day or two in situ, so that this kind of local provocation, with its consequences, is rarely encountered.

It may be possible by expert use of the laryngoscope to see a tumor located within the trachea. If the patient cannot tolerate its use the parts may be made tolerant by the use of a weak cocaine spray. Such a growth, if accessible from above, may be removed through the glottis by forceps. Most operators, however, prefer to make an opening through the trachea and thus profit by the larger surgical opportunities thus afforded. Such an operation should be made with the patient’s head low in order that blood may gravitate to the pharynx rather than to the lungs.

OPERATIONS UPON THE LARYNX.

Cancer of the larynx was regarded, until the last quarter of the previous century, as an absolutely hopeless condition for which nothing could be done until it became necessary to do a tracheotomy, this simply affording relief from some of the distressing features, but aiding nowise to check the progress of the growth. The first demonstration of the possibility of successful removal of the larynx was made by Czerny, in 1870, upon dogs. Watson, of Edinburgh, had removed a syphilitic larynx in toto in 1866, but this summary operation only became known to the world through a publication of Foulis in 1881. Meantime, Czerny’s experiments were so successful that Billroth was induced to attempt the removal of the entire larynx in a case of cancer, with results which astonished the profession of that day. Thus introduced, nevertheless, the mortality rate was great, the principal cause of death being inspiration pneumonia—that is, rapid infection of the lung through the widely opened trachea and the entrance of saliva and fluids from the mouth. Hahn, of Berlin, undertook the improvement of the technique and was able to reduce the mortality from this cause. Meantime another radical method—namely, thyrotomy, i. e., opening the laryngeal box—had not fared much better than the measure just mentioned. Thus until about twenty-five years ago the radical treatment of laryngeal cancer stood in an unpleasant light, partly because diagnostic methods were unsatisfactory and our general knowledge of the disease incomplete, partly because operation was always delayed until late, and because operative measures had yet to be much improved. Tremendous impetus was given to the whole subject by the celebrated case of the Emperor Frederick, and the acrimonious criticisms concerning its conduct were not without benefit, since they led to a careful re-study of the whole situation, with its numerous subsidiary questions, among which was the possibility of transformation of a benign into a malignant tumor. At present, largely through the labors of Hahn and Billroth, in Germany, and Semon, in London, the question of operative procedures is fairly settled, everyone now believing that the disease should be radically attacked at the earliest possible moment, opinions differing only in regard to the route which the surgeon should adopt, i. e., whether he should make an intralaryngeal operation, as is now favored in Germany; a thyrotomy, as preferred in Great Britain, or a laryngectomy, as some of the general surgeons in all parts of the world prefer.

The different methods of attack upon the larynx for cancer may then be summarized as including intralaryngeal extirpation through the natural passages, thyrotomy, and partial or complete laryngectomy.

The intralaryngeal method, seen from the general surgeon’s view-point, can only be suitably applied to a limited class of cases which are recognized early, and may be best performed by an expert laryngologist, i. e., one accustomed to instrumentation within the pharynx and larynx. It includes the use of various instruments for the excision of small areas, for the application of the galvanocautery, etc. The writer agrees with Semon in regarding it as irreconcilable with the principles which should guide us in dealing with malignant growths, the fundamental one being the removal not only of the growth itself but of an area of surrounding tissue. This intralaryngeal method may then be satisfactory in the removal of benign growths, but will seldom appeal to the operating surgeon when he deals with cancer. Epithelioma may commence at the accessible tip of the epiglottis, but intrinsic cancer of the larynx should be dealt with in a more radical manner. Thyrotomy is the operation of choice, especially among the British laryngologists. It seems rational to believe that in cases where diagnosis is made early a thyrotomy, with removal of the growth and a wide area of surrounding tissue, including portions of cartilage, if necessary, may prove the ideal operation, while vocal results are better than after extirpation. It is necessary, however, that diagnosis should be made early and that operation be made thoroughly; while if, after opening the thyroid, it should appear that complete extirpation of the growth is otherwise impossible, then the operator should make a complete laryngectomy.

All of these operations are best preceded by use of a cocaine spray, by which extreme irritability of the interior of the larynx is allayed, and the reflex lowering of blood pressure prevented. (See p. 178.)

Thyrotomy is performed as follows: The patient is preferably in the position with down-hanging head. An incision in the median line, about three inches in length, is made from the upper border of the thyroid cartilage down to a point below the cricoid. With but slight separation of the tissues it is made to extend directly down upon the abrupt ridge-like anterior border of the thyroid cartilage, below which will be exposed the cricothyroid membrane. Into this the knife may be inserted and made, with cutting edge up, to split the halves of the larynx exactly in the middle line, the blade passing between the vocal cords, unless they have been much distorted by the growth. In that case the dissection may be made more deliberately. The larynx being thus split, the cricoid should be divided, after which, with suitable retractors, the interior is exposed to such an extent as to permit both inspection and palpation. Through the opening thus afforded all suspicious tissue should be removed, from one side or both, the primary question being not what will be the resultant effect upon the voice, but how best to completely eradicate the cancerous tissue. With the patient’s head hanging downward there is less likelihood of the entrance of blood into the trachea. Nevertheless the tampon cannula should always be accessible so that it may be inserted should it be required. The tampon cannula is a trachea tube around which there is a small rubber bag, with a tube through which it may be inflated, so that after the cannula is introduced into the trachea it may be tamponed by air pressure in such a manner as to permit no passage of blood.

In the absence of one of these specially designed tubes an effective substitute may be made by the ordinary trachea tube wrapped with a covering of antiseptic gauze, the latter held in place by a few turns of fine silk or catgut.

The thyrohyoid membrane bears the superior laryngeal vessels and nerves, and it should be entered through the middle line in order not to disturb these. Whatever operation may be required upon the tissues within the laryngeal box may be conducted with knife, scissors, curette, and the fine point of the actual cautery. The interior of the larynx should be cleaned, leaving it simply as a part of the respiratory tube, without reference to what may become of the structures within it devoted to voice production. The cartilaginous shell, with or without a part of its previous contents, having been rid of the suspicious tissue within, it may be held together by one or two sutures of silver wire or by superficial sutures of chromic gut, while the trachea tube which may have been used may be left for a day or two, or removed at the time. Ordinarily the latter course will prove the better.

Laryngectomy, or total extirpation of the larynx, is the most severe procedure of all, but will be requisite when there is evidence of escape of malignant growth from within the true confines of the laryngeal box. Not only the larynx but more or less of the surrounding tissue may be removed, with infected neighboring lymphatics, the upper portion of the trachea, and the base of the tongue.

The operation may be preceded by a low tracheotomy or otherwise. If necessary this should be done several days in advance, in order that the patient may have become tolerant of the tube and of the new method of breathing. If requisite the ordinary trachea tube may be substituted for the tampon tube above described, in which case it will not be necessary to lower the patient’s head. Otherwise the operation is perhaps best performed with the head and neck in the Rose position.

The incision is a long median division of tissues from above the hyoid to an inch or more below the cricoid cartilage. Through it the anterior border of the thyroid should be easily exposed. It is then necessary to separate on either side the sternohyoid and sternothyroid muscles, the lateral mass of the thyroid body being drawn to either side along with the musculature, the isthmus having been previously doubly ligated and divided for this purpose. Now as rapidly as may be the larynx is completely isolated from all the structures around it, the dissection being bluntly made. After freeing it on both sides it is drawn forward, first to one side, then to the other, so that on either side the superior laryngeal artery may be exposed and secured, the superior laryngeal nerve being necessarily divided. The cricothyroid branches need also to be secured, as well as any other vessels which may spurt blood. Circumferential isolation of the larynx is now completed by dividing the inferior constrictor of the pharynx and separating it from the side of the thyroid, keeping close to the cartilage. After this isolation is completed the surgeon has the choice of first dividing the respiratory tube either above or below the larynx. This will depend largely upon his own choice, but usually the procedure is easier when the first division is made either through the cricothyroid membrane or between the cricoid and the upper ring of the trachea or even below this point, if necessary. With a low division first the patient will immediately begin to breathe through the opening thus made unless a previous tracheotomy has been done. Ample time will be afforded for the introduction of a trachea tube and protection around it to prevent entrance of blood, when the larynx may be lifted and separated with knife or scissors from the tissues remaining attached. The esophagus begins at the level of the cricoid cartilage, and if the cricoid is to be removed the esophagus should be separated from it; otherwise it is not disturbed. Last of all, in this order, the thyrohyoid membrane will require division, and then the extirpation is completed.

The wound is large, the communication with the oropharynx is unobstructed, and there will be constant escape into the newly formed cavity of secretions from the nose and mouth. At first the patient will be unable to swallow, although there may be constant desire to reflex attempts in this direction. The questions to be decided are the management of the wound in gross and the suitable treatment of the upper end of the trachea, as well as of the esophagus, if this has been touched. The greatest danger is that of inspiration pneumonia. Other consideration should be secondary to that of prevention of the escape of fluids down the trachea and the consequent production of pneumonia. General experience is rather to the effect that the best results are obtained with a minimum of sutures, the large cavity being lightly packed with absorbent material, while the upper end of the trachea should be sewed to the skin as high as possible on either side, the esophagus being allowed to take care of itself. The patient should wear a trachea tube for several days after the operation. Through the exposed upper end of the esophagus a tube may be passed three or four times a day, and sufficient nourishment be thus introduced into the stomach. The patient may be kept lying upon the side for the greater part of the time, so that saliva may escape from the mouth.

The question comes up later as to what substitute, if any, may be afforded for the lost larynx. Gussenbauer devised an improvement on what was called the “artificial larynx,” devised originally by Foulis and then modified by Hahn, which afforded an ingenious mechanical substitute for the larynx, permitting the production of voice by vibration of a metallic reed, such tone as it produced being, like that produced by the vocal cords, modified by the vocal organs above into perfectly intelligible speech, but always in a monotone. It consisted of a tracheal tube through whose external opening another tube could be passed upward to a point where it lay beneath the epiglottis, if this were left in situ, or behind the base of the tongue, if the epiglottis had been removed. Through this the patient could breathe under ordinary circumstances. By a little device at the external opening the touch of the finger upon a spring would throw into the air current a thin, metallic reed, by whose vibrations tone was produced, to be modified as mentioned above. This was the principle of the artificial larynx which was worn by many patients and which in many gave good results. One patient of my own wore one for seven years, although he discontinued using the reed because the peculiarity of the tone attracted more attention than did the loud “stage whisper” which he had cultivated. Around the instrument there is always more or less moisture or discharge, and there are many disagreeable features attending its use, even though it permit the act of swallowing without any difficulty.

Solis Cohen introduced a method of treating these cases by fastening the trachea to the external wound and permitting the cavity above to close as rapidly as possible. In this way the trachea is permanently terminated in the middle of the neck and patients breathe through this opening. It has been found that with practice they can retain sufficient air in the mouth and pharyngeal cavity to permit them to whisper several words at a time. This simplifies the procedure, and is now usually adopted after extirpation of the larynx.

Partial laryngectomies have been practised through external openings, one lateral half or more of the larynx being removed. These operations have been few in number and often unsatisfactory. They should be reserved for cases with favorable indications. When required they are performed on the same principles as those already outlined, only the extirpation is incomplete. Certain modifications have been proposed by individuals, as, for instance, the suggestion made by Gluck, to suture the opening in the trachea to a buttonhole opening made in the overlying skin, by which means he thought to prevent inspiration pneumonia.

OPERATIONS UPON THE TRACHEA.

Tracheotomy is the general term made to cover any opening into the lower air passages between the larynx proper and the upper end of the sternum. Laryngotomy, cricotracheotomy, tracheotomy, etc., may be described as implying by these names the exact location of the opening. The principle is, however, the same, and the details of the operation vary but little.

Tracheotomy as a deliberate operation is different from tracheotomy as it was formerly practised for diphtheria, and as it is yet done in emergencies, some cases being so serious that suffocation will occur if the opening be not promptly afforded. In the former case preparations can be made; in the latter, operation may have to be done with the blade of a penknife. It makes considerable difference also whether an anesthetic can be used. To administer chloroform to a child with a heart already weakened by the toxins of diphtheria is almost to invite disaster, and yet to do the operation without an anesthetic is perhaps impossible.

The middle line is the line of safety in all of these operations. The danger of heart failure from the anesthetic, or of suffocation from tardiness of relief, being passed, the other principal danger is that of hemorrhage. The isthmus of the thyroid may be divided, but always with preliminary ligatures, or it should be caught between the blades of pressure forceps on either side before dividing it. A patient with a short, fat neck, whose cervical veins are dilated and engorged with venous blood owing to partial asphyxia, makes a difficult and undesirable subject. The trachea lies nearer the surface at its laryngeal end than in its lower portion—i. e., if the operation be low in the neck deep search will have to be made for the tube. The first incision should be made sufficiently long, never less than two inches, and should be so planned as to bring the operator down upon the tracheal rings. By this time sufficient engorged veins may have been divided to cause a serious oozing of dark, venous blood, by which the field of vision is much obscured. Except in emergencies the surgeon may wait for this engorgement to be relieved. The trachea, being recognized by the finger-tip, is seized with a tenaculum, by which it may be held forward, and then at least two of its rings divided with the knife-blade. The instant the opening is made, if the patient be still breathing, bloody foam and frothy blood will be ejected, and for a moment or two the bleeding may be uncontrollable. Under these circumstances the normal blood color soon returns. Artificial respiration should be practised at the same time. Supposing this to be an emergency case, with little or almost nothing at hand, sutures should be passed through the tracheal opening and through the skin margin on either side. If no other retractor be at hand the suture materials may be left long and tied behind the back of the neck, sufficient tension being made to prevent the wound edges from coming together. Formerly when the surgeon was called to do this operation with little or no help the writer has extemporized a couple of retractors out of hair-pins, bent for the purpose, hooked into the tracheal wound, then tied with tapes, which were united behind the neck, while the wires were kept from being pulled out of place by a skin suture on each side. There is now less occasion for these crude methods since the introduction of O’Dwyer’s intubation.

With tracheotomy done deliberately, and at the point of election, usually above the thyroid isthmus, with or without division of the cricoid, the vessels may be secured as they are exposed or bleed, and the trachea should not be opened until all oozing from its exterior has been checked. For this purpose the patient is placed upon the back, the shoulders raised, the head thrown backward, and the neck exposed, a pillow being placed beneath. (See Fig. 482.) The operation may be done under cocaine local anesthesia or with a general anesthetic. Incision in the middle line, below the lower border of the thyroid cartilage, is made two inches or so downward, the fascia beneath being divided in the same line and the tissues retracted to either side from this median exposure. Thus one makes access to the cricothyroid membrane, the cricoid, the upper tracheal rings, and the thyroidal isthmus. According to the size and location of the latter (it usually lies in front of the second tracheal ring) it may be retracted or doubly ligated and divided in the middle. The difficulty now afforded is from the upward and downward play of the larynx, which may occur during forced efforts at respiration. To steady it a tenaculum should be introduced just above the cricoid, a little to one side of the middle line, firmly fastening it. With this held in the left hand, thus steadying the parts, a sharp-pointed knife is so employed as to divide the cricoid and one or two upper rings of the trachea, being cautious not to wound the posterior wall. The opening thus made should be about one-half inch in length. Through it a second hook is now passed into the other side of the cricoid and the incision held open by their agency while the trachea tube is introduced.

This procedure may be modified in accordance with any local indications, and may be made according to the needs of the case. When the opening is made into the trachea below the isthmus it is called a low tracheotomy. Here the anterior part of the trachea lies free from the skin, but may be covered with a plexus of veins connecting with the inferior thyroid. Farther down the arteria thyroidea ima may be encountered. There is always reason for operating as high as the case will permit. The trachea may itself be displaced by the growth which compresses it and necessitates the operation. Thus it may be crowded to one side, other anatomical relations being disturbed, or it may be compressed into scabbard shape, and thus be difficult to find or to open.

The moment the trachea is open more or less marked expulsive efforts will drive blood and foam in all directions, and may for a moment obscure the field of vision. Every precaution should be taken to prevent the entrance of blood into the trachea. Pressure of the tracheal walls against the tube to be inserted may check hemorrhage from its margins. The operator should be ready to suspend all other procedures and make artificial respiration, and he should also be prepared to open the trachea suddenly, should impending suffocation require it.

In a general way, then, the indications for tracheotomy are symptoms of rapidly or slowly threatening obstruction to respiration from causes either within the larynx—e. g., diphtheria, foreign bodies, tumors, and the like—or causes external to it, such as tumors, phlegmons, cicatrices, etc. Any cause which interferes with the free play of air through the respiratory tube, which can be either relieved or atoned for by the operation, will always justify it.

Tracheotomy tubes are mechanical devices for not only keeping the tracheal wound open but permitting the unobstructed passage of air. They are made of various materials, of which silver is the most satisfactory, as aluminum is too easily acted upon by the fluids of the body, and rubber occupies too much space. The tracheotomy tube is a double tube, the inner one slipping easily into and out of the outer, and being necessitated by the ease and abundance with which secretions may collect and dry, and thus obstruct. Were it necessary to remove the entire tube for each cleansing, difficulty might be met in re-introducing it, whereas the inner tube is easily removed, quickly cleansed, and restored to place within the outer without disturbance or pain to the patient.

Aside from the tracheal tubes ordinarily used there are others made exceptionally long, and with flexible lower ends, which may be used in case of tumor low in the neck or high in the mediastinum—for instance, in cases of enlarged thymus, where it is necessary to go beyond an obstruction.

In the after-care of these cases it should be remembered that air passes directly into the lung without being warmed, or moistened, by passage over the mucous membrane of the upper respiratory tract. The patient, therefore, should be kept in a warm room, and the air should be kept moist by the use of a croup kettle or a spray machine. The inner tube should be kept unobstructed, the length of time during which it should remain depending on the nature of the case. So soon as its usefulness is passed it should be removed. A tracheotomy wound kept open but for a day or two will quickly close, but one which has remained open for weeks may close with difficulty, and then there may be trouble from granulation stenosis or cicatricial contraction. (See above under Stricture.) In instances where a permanent opening is to be maintained it is desirable to remove the tube as early as circumstances may permit.

INTUBATION.

The perfection by Joseph O’Dwyer of a method, at which others had worked, of substituting intubation of the larynx for the old tracheotomy, not only shed the greatest luster upon his own name, but has afforded a speedy and bloodless method of accomplishing much more than had been previously possible by the older procedure. The method comprises the emplacement of a suitably sized and shaped tube within the larynx, by a manipulation guided almost entirely by the sense of touch, for the relief of suffocative symptoms due to disease at this level, and leaving the tube in situ for a sufficient time to permit morbid activity to subside and justify its removal.

It is advisable to have a half-dozen tubes, varying in size from 1¹⁄₂ inches to 2¹⁄₂ inches in length, and of corresponding increase in other dimensions, each of which affords a passage-way for respiratory purposes, and is also provided at its upper end with a flange, which shall rest upon the false vocal cords and prevent the descent of the tube into the trachea below. The complete set of instruments as now furnished by all the manufacturers provides an assortment of these tubes, with a scale indicating which one to use upon a patient of a given age, and includes a mouth-gag, which may be used for many purposes, and two handled instruments—one intended for the introduction, the other for the extraction of the metal tubes.